How would you handle this case?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

BuzzPhreed

Full Member
7+ Year Member
Joined
Jan 9, 2014
Messages
1,224
Reaction score
648
So I've posted on the Anesthesiology forum. Exclusively. Until now.

Here's a hypothetical case I want to see how you guys would handle...

47 y.o. male comes to ED with 3-4 day history of progressive diarrhea. Worse over the last 24 hours. No fever. But hypotension, tachycardia. Hyperactive bowel sounds, but no peritoneal signs. Appy is still present (i.e. no prior abdominal surgery). WBC's are 21k. Lightheadeness, non-vertiginous. No chest pain, no shortness of breath. Reports he has continued his home meds. No recent antibiotics. No recent travel. No recent sick contacts he's aware of.

Relevant history: chronic HTN, intermittent EtOH abuse/recovering alcoholic (none recently per patient), anxiety/depression, T&A as a child, knee scope in the past

Home meds: Celexa, Trazadone, Librium, lisinopril, Ativan PRN

Social: prior heavy ethanol intake (none in past 6 months, per patient), non-smoker, no illicit substances, works as an attorney, married and lives with wife, no children

PE: BP 68/40, P-116, T=37.2, R-20, SpO2 = 98% on 2L
Gen: awake, conversant, non-diaphoretic, not clearly in distress
Chest: clear, no wheezes
Card: tachy, regular
Abd: NT/ND, thin
Extr: thin, poor skin turgor, pulses thready
Neuro: CN 2-12 WNL, non-focal

Rest of exam is WNL

Tests already done: BUN = 57, Creat = 2.7, K+ = 3.1, Na+ = 136, WBC = 21k, 11% bands; Hb/Hct = 14.1/42%, heme (-) stool, CT scan negative for acute intrabdominal process, C. diff toxin (-), EKG sinus tach, no ST-T wave changes, 1st troponin negative, stool O&P sent (pending)

How would you manage this patient? Would you push to admit them?

Members don't see this ad.
 
Last edited:
Um, I guess my question would be why wouldn't you admit them? You have someone who is probably in a suboptimal state of health at baseline, who is now presenting with massive dehydration, AKI, who really has severe sepsis by criteria. Is he even making urine at this point? How do you know his kidneys are going to improve and not just shut down completely? You CTed him and made surgical pathology less likely, but have you fixed anything at this point? He obviously didn't do well at home, what has changed?

The question of abx is more debatable if you're thinking that this could be an E. Coil infection. You didn't mention if there was any bloody diarrhea?
 
My "hypothetical" answer to your hyoothetical case:


Symptoms of hypovolemic shock on arrival (BP and hr) with at least one end-organ system failing (renal)? Resuscitate? Admit?



Uhh....yes and yes.


But I see where you're going with this, as the best part of your presentation, by far, is the social history: "works as attorney."
 
Members don't see this ad :)
1) No bloody diarrhea (the Hemoccult was negative).
2) He did not disclose right away that he was an attorney

So here's what happened in this... ahem... "hypothetical" case....

This "hypothetical" patient was prescribed 2L of 0.9% NS by the nurse practitioner... then sent home. He was told to come back if he "didn't feel better". He was not prescribed any motility agent (not that this would be indicated). He was instructed to follow-up with his PCP during the same week. He never saw the CRNP or the ED doc after the initial evaluation in the ED. When the nurse told him to get dressed and brought his discharge papers, he almost syncopized when he stood up.

He re-presented approximately 8 hours later, still hypotensive. Still with diarrhea. He was charged for a second ER visit. At this point, he informed them that he was an attorney. 3-day admission. No WBCs in stool. O&P subsequently negative. Likely an norovirus (no specific viral RNA testing done), at least that was what he was told as the presumptive d/c diagnosis.
 
I'm glad that first trop was negative. I've seen lots of NSTEMIs present as progressive diarrhea.

Even though he was relatively healthy prior to this, the AKI makes me want to admit him, especially after the CT (even though some people dispute the existence of CIN). If, after hydration, he felt better and wanted to leave, I wouldn't call the police or anything, but I'd still recommend at least an obs admission.
 
I saw a case very much like this, except that the patient was a doctor, not a lawyer. He was very resistant to admission. So, after several liters of IVF in the ED I rechecked renal fxn - it was improved, as was his BP and he went home to orally rehydrate.

I assume you would've told us if there was a rash, low platelets or evidence of hemolysis?
 
We seem to have different definitions of "hypothetical".

;)

I assume you would've told us if there was a rash, low platelets or evidence of hemolysis?

Yeah, none of that stuff. He never vomited either. Just progressive watery diarrhea. Never had a fever, rigors, cough, etc. either. Left the hospital better, but with no definitive diagnosis.

Makes me wonder if this was somehow related to meds and/or hx of EtOH abuse. I "hypothetically" know this patient. He's "hypothetically" reliable. Not always honest about his drinking...
 
Also don't know if this is de rigueur in the ERs you guys work in, but to never physically see the doctor? And to be discharged with a creatinine like that? Scary.
 
So I've posted on the Anesthesiology forum. Exclusively. Until now.

Here's a hypothetical case I want to see how you guys would handle...

47 y.o. male comes to ED with 3-4 day history of progressive diarrhea. Worse over the last 24 hours. No fever. But hypotension, tachycardia.

Tests already done: BUN = 57, Creat = 2.7, K+ = 3.1, Na+ = 136, WBC = 21k, 11% bands; Hb/Hct = 14.1/42%, heme (-) stool, CT scan negative for acute intrabdominal process, C. diff toxin (-), EKG sinus tach, no ST-T wave changes, 1st troponin negative, stool O&P sent (pending)

How would you manage this patient? Would you push to admit them?

There is no way in hell I am discharging this patient. Whoever did got really lucky.
 
This would be an admit nearly 100% of the time. I'd give 2L IVF then admit. This isn't something I would have spent much time thinking about. I'm a resident at a large academic medical center.

If his abdomen is nontender, I probably wouldn't have scanned him. Would have sent LFTs. Do not even know how to order O&Ps, lol - not something that ever gets ordered from our ED. With the tachycardia and hypotension, I'd probably get a urine and CXR as well. I'd also want to know a little more about how he was taking his meds. Would be atypical for benzo withdrawal or serotonin syndrome, but not entirely impossible.

There's a lot of variation in what states require of midlevel supervision (which I'm guessing you're acutely aware of seeing as your an anesthesiologist). Some midlevels are great, some are terrifying.
 
I know individual shops have varying levels of supervision. I'm also aware that, at this particular hospital, there is a large contracted management company that supplies the docs and NPs. In his case when he came back it was a new team. This time they called his PCP and decided to admit. They planned on a 23 hr with re-checks, but this turned into a 3-day admission.

This "hypothetical" patient seemed to be most pissed about the 2nd charge for the ED visit. That was the thing that he is currently discussing with their billing department and trying to get waived.

This did not hypothetically happen at my current hospital. In fact, it was hypothetically even in a different state from where I practice.

I told him what I would've "hypothetically" done (you see, we're not allowed to discuss [per SDN rules] actual cases, which is why I'm discussing this hypothetical one) and that would be to admit and watch, at least continue the IVF until he was asymptomatic and/or feeling better especially with a bumped creatinine.

There's a lot of variation in what states require of midlevel supervision (which I'm guessing you're acutely aware of seeing as your an anesthesiologist). Some midlevels are great, some are terrifying.

Don't get me started. :laugh:
 
Diarrhea with acute renal failure (presumed, as we don't know the prior Cr). This can lead to metabolic derangement, with the K+ of 3.1. Did anyone check the magnesium? 2-3L IVF, check the numbers (including urine), maybe an AXR (why CT? I order more AXRs than anyone else), and, if he doesn't get a LOT better, easy admission.

These are one of those "you don't know what you don't know" cases. "The eye does not see what the mind does not know" - if the NP looked right at, and past, the Cr of 2.7, there's the problem.
 
Members don't see this ad :)
Diarrhea with acute renal failure (presumed, as we don't know the prior Cr). This can lead to metabolic derangement, with the K+ of 3.1. Did anyone check the magnesium? 2-3L IVF, check the numbers (including urine), maybe an AXR (why CT? I order more AXRs than anyone else), and, if he doesn't get a LOT better, easy admission.

These are one of those "you don't know what you don't know" cases. "The eye does not see what the mind does not know" - if the NP looked right at, and past, the Cr of 2.7, there's the problem.

Yep.

(And aside from a transaminitis about two years ago from an EtOH binge, and ruled-out acute viral hepatitis at the time, baseline creatinine is normal in this dude... "hypothetically".)
 
I'll say up front that I'd admit the guy based on the Hypothetical... but also, hypothetically, if his baseline Creatinine is 2.5 and the initial BP is bull**** and/or improves to 120/80 after 2000cc IVF bolus and the guy's is up dancing around feeling 1000% better and has to go home to feed his dog I might consider discharge.
 
I'll say up front that I'd admit the guy based on the Hypothetical... but also, hypothetically, if his baseline Creatinine is 2.5 and the initial BP is bull**** and/or improves to 120/80 after 2000cc IVF bolus and the guy's is up dancing around feeling 1000% better and has to go home to feed his dog I might consider discharge.

Not unreasonable if he's substantially improved. And I think therein is the rub. No one (aside from the ED nurse) came and re-evaluated him after he got the bolus. I think the assumption was that he would be better, in the face of not having significant underlying co-morbidities.

I think that was the part that bothered me the most. Neither the NP nor the doc in charge that day came by to see if he'd actually improved by any clinical measure (urine output, symptoms, etc.). I'm sure someone looked at his follow-up BP and thought he was fine. He wasn't. Total bounce-back. Legitimately so.
 
Not unreasonable if he's substantially improved. And I think therein is the rub. No one (aside from the ED nurse) came and re-evaluated him after he got the bolus. I think the assumption was that he would be better, in the face of not having significant underlying co-morbidities.

I think that was the part that bothered me the most. Neither the NP nor the doc in charge that day came by to see if he'd actually improved by any clinical measure (urine output, symptoms, etc.). I'm sure someone looked at his follow-up BP and thought he was fine. He wasn't. Total bounce-back. Legitimately so.

I'm going to assume he had improved by some clinical measure of improvement in that most hospitals require VS within x (usually 0-60 min depending on severity) minutes of pt being discharged. So it's unlikely that his hypotension or tachycardia was still present on discharge. If he's still pooping but not vomiting, I don't really know how that changes my dispo since it's unlikely I'm going to fix the diarrhea in the ED (unless I request a stool sample which is possible the most constipatory action I can take). Unless I'm waiting for a UA, it's unlikely I'd be aware his urine output (I know everywhere in medicine lives and dies by it but it doesn't fit well into nursing work-flow and it's not available consistently enough to be a routine part of our MDM). With that being said, this is a guy that from initial vital signs and presumably bumped Cr that I would have slotted for admission for rehydration and r/o more insidious badness (I see plenty of diarrhea, I don't see plenty of diarrhea causing hypovolemic shock). Especially given that I'm sure the CT was a non-con with that Cr and there are things a non-con will miss that would be clinically important.
 
If he's still pooping but not vomiting, I don't really know how that changes my dispo since it's unlikely I'm going to fix the diarrhea in the ED (unless I request a stool sample which is possible the most constipatory action I can take).

I see what you did there.

And I like it.
 
Forget the discussion about admission vs d/c.

This sounds like more a discussion between admitting to floor vs. stepdown. I'd push for a stepdown admission given the abnormal vital signs (this is assuming they improve with fluid resuscitation).
 
Why observation? (You mentioned observe the guy for 23 hours). Acute renal failure qualifies for inpatient criteria, and there's no reason your hospital shouldn't get paid properly for a legitimate diagnosis.

Point taken.

Still no matter what I think the guy gets at least an overnight stay, and a re-check of his creatinine in the morning -- and NOT to be sent home. If his creatinine is WNL in the AM, I'm not sure you could retrospectively justify a full admission. The "two midnight" rule might bite you during a CMS audit if you send him home the next day. Especially if you do that too much. They could argue that he recovered sufficiently from the dehydration/tachycardia that he never deserved an admission, and that acute renal failure isn't really the primary diagnosis here. (Upcoding can also nail you, too, if you pull it too much. Forget just paying them back. They fine your ass and make you submit EVERYTHING during a "probationary" period before they pay you.)

But I read you. He meets the criteria for AKI. And in this case he stayed three days after he came back, so obviously he should've been admitted in the first place. Floor vs. step-down is an even finer point to argue.
 
Forget the discussion about admission vs d/c.

This sounds like more a discussion between admitting to floor vs. stepdown. I'd push for a stepdown admission given the abnormal vital signs (this is assuming they improve with fluid resuscitation).

Depends on what your floor vs. step-down capabilities are. As presented, unless the patient had continuous hypotension it's tough to argue that he needs stepdown level care and putting him in there is going to hose your ability to get ICU beds for your sicker patients.
 
I think 100% of emergency physicians I've worked with would admit this patient.

It sounds like severe sepsis with a suspected abdominal source. I'd give the patient 2 liters of crystalloid, Levaquin, Flagyl, and admit to SDU or MICU. If it turns out later to be viral diarrhea and hypovolemia, that would be a diagnosis of exclusion for us in the ED. They can narrow or discontinue the antibiotics later. Done.

There are way too many red flags in that case to discharge the patient – WBC, renal failure, etc.

If the patient declined to be admitted, that would be okay. But I'd have him sign paperwork and document this discussion in the medical record.

In my ED, I staff cases with NP's when they either ask me to, or the patient requires admission. If the patient is being discharged and the NP is comfortable with the case, I am not involved in their care. It has to do w/ the parameters of their contract w/ our hospital. Our NP's tend to be very conservative, and I'm quite confident they would've admitted this patient. It sounds like that NP mismanaged this patient.
 
Last edited:
  • Like
Reactions: 1 user
The BP with any abd complaint makes me worry about a AAA.
I would never send this guy home, unless he leaves AMA.
The real question is how big a workup I'd do in the ED.
Sounds like labs (including lactate), fluids, abx, CT and admit.
 
Look, I would've admitted this patient too - it would've been the easiest admission of my shift.

But just to play the Devil's Advocate, let's look at what happened - he came back got tanked up on fluids and then went home with a Dx of norovirus. The literature is overflowing with data and recommendations that PO rehydration > IV rehydration. I agree with Apollyon that the reason to admit is mainly because you don't know what's going to happen prospectively, but in retrospect, this patient probably could have done OK at home with $2 worth of homemade oral rehydration solution and a handful of Zofran. Instead he got a several thousand dollar hospital stay.

When I saw this same patient, except that my patient was a doctor, he very knowledgeably declined admission, and just like the lawyer, he recovered.

The main concerns of the patient and the OP does not seem to be some unfortunate outcome or harm done - it's that there was a charge for the second ED visit and that the patient wasn't seen by an MD.
 
I hear you... but he meets sepsis criteria. I've admitted too many patients to count where I put "sepsis" on the admitting diagnosis simply because they meet criteria but I'm skeptical as to whether they are actually septic. We simply don't have the luxury of foresight in the ED and can't afford the risk to be wrong when someone meets overwhelming admission criteria. Hospitalist drinking rounds are replete with stories like these where they snicker at the ED docs who admitted a gastroenteritis as "sepsis" but they have the luxury of rapid clinical improvement and "no growth at 2 days" with copious other studies. I could do my absolute best documentation on someone like this to justify discharge and still get easily shredded by the dumbest lawyer in town after a bad outcome.

I think we've all had cases that push the envelope so to speak and we were able to discharge them after some creative management but my personal policy is that if they meet sepsis criteria and don't want admission... they sign AMA, period. I don't care if it's the queen of England.

If the guy was pissed about two ED visit charges, risk management should probably get involved to get one of them dropped.
 
The patient had severe sepsis, it just happened to be from a viral etiology…

At my shop, this case would've resulted in a few meetings and phone calls. Because the nurse practitioner made an error in judgment and he should've been admitted on the first visit, the patient's grievance was warranted. His charges likely would be adjusted, and he would only be charged for a single visit.
 
Depends on what your floor vs. step-down capabilities are. As presented, unless the patient had continuous hypotension it's tough to argue that he needs stepdown level care and putting him in there is going to hose your ability to get ICU beds for your sicker patients.

Based on the OP's H &P the pt clearly presented in septic shock. Even if you 'tank him up' with 2 or 3 litters of crystalloids his sepsis could easily progress several hours later requiring a line and pressors. Stepdown monitoring would presumably alert a physician to this faster than the floor would. Admitting a patient who presented in septic shock to the floor would make me very nervous at my hospital.

If he had continuous hypotension despite resuscitation, he is going straight to the ICU. No questions asked.
 
Based on the OP's H &P the pt clearly presented in septic shock. Even if you 'tank him up' with 2 or 3 litters of crystalloids his sepsis could easily progress several hours later requiring a line and pressors. Stepdown monitoring would presumably alert a physician to this faster than the floor would. Admitting a patient who presented in septic shock to the floor would make me very nervous at my hospital.

If he had continuous hypotension despite resuscitation, he is going straight to the ICU. No questions asked.

Presumably not septic shock. If they were still hypotensive after fluid bolus, I suspect they would have not been DC'ed.

I would have a hard time getting this to a step-down unit at my hospital. I would have admitted to the floor if improvement in VS.

If the patient wanted to be DC'ed after IVF and improvement, I don't know that I would have made the patient sign AMA. I'm not horribly impressed with the "protection" that an having a patient sign out AMA gives you. I usually just try to document very clearly in my chart what happened.
 
  • Like
Reactions: 1 users
Who knows if the patient's attorney is reading this forum right now, but this patient should have never been sent home.
 
So I've posted on the Anesthesiology forum. Exclusively. Until now.

Here's a hypothetical case I want to see how you guys would handle...

47 y.o. male comes to ED with 3-4 day history of progressive diarrhea. Worse over the last 24 hours. No fever. But hypotension, tachycardia. Hyperactive bowel sounds, but no peritoneal signs. Appy is still present (i.e. no prior abdominal surgery). WBC's are 21k. Lightheadeness, non-vertiginous. No chest pain, no shortness of breath. Reports he has continued his home meds. No recent antibiotics. No recent travel. No recent sick contacts he's aware of.

Relevant history: chronic HTN, intermittent EtOH abuse/recovering alcoholic (none recently per patient), anxiety/depression, T&A as a child, knee scope in the past

Home meds: Celexa, Trazadone, Librium, lisinopril, Ativan PRN

Social: prior heavy ethanol intake (none in past 6 months, per patient), non-smoker, no illicit substances, works as an attorney, married and lives with wife, no children

PE: BP 68/40, P-116, T=37.2, R-20, SpO2 = 98% on 2L
Gen: awake, conversant, non-diaphoretic, not clearly in distress
Chest: clear, no wheezes
Card: tachy, regular
Abd: NT/ND, thin
Extr: thin, poor skin turgor, pulses thready
Neuro: CN 2-12 WNL, non-focal

Rest of exam is WNL

Tests already done: BUN = 57, Creat = 2.7, K+ = 3.1, Na+ = 136, WBC = 21k, 11% bands; Hb/Hct = 14.1/42%, heme (-) stool, CT scan negative for acute intrabdominal process, C. diff toxin (-), EKG sinus tach, no ST-T wave changes, 1st troponin negative, stool O&P sent (pending)

How would you manage this patient? Would you push to admit them?

I didn't read all of the answers and I must be missing something but this seems so straight forward. I don't even see why anyone would push back on an admission. Any of these reasons below would warrant an admission given symptomatic state.

1. Hypotension
2. Tachycardia + WBC 21
3. CR 2.7 (assume new)


And those are the obvious ones. Other red flags - Bandemia,
 
Presumably not septic shock. If they were still hypotensive after fluid bolus, I suspect they would have not been DC'ed.

I would have a hard time getting this to a step-down unit at my hospital. I would have admitted to the floor if improvement in VS.

If the patient wanted to be DC'ed after IVF and improvement, I don't know that I would have made the patient sign AMA. I'm not horribly impressed with the "protection" that an having a patient sign out AMA gives you. I usually just try to document very clearly in my chart what happened.

Sorry, yes technically not septic shock yet but severe sepsis at the very least. He has a 11% bandemia, that is concerning...I don't know how anyone could d/c that.

There were a couple of EM:RAPs on AMA. I don't think signing the paper really matters much. As long as you document capacity, understanding of risk, and possible outcomes you are as covered as you are going to be.
 
I'll avoid the blatant "Hire a PA instead of NP", nor will I refer to the ACEP policy that makes PAs the preferred "midlevel" provider in the ED.

This hypothetical NP, or any other provider who would send home such a hypothetical patient, needs remediation and closer supervision.
 
  • Like
Reactions: 1 user
I'll avoid the blatant "Hire a PA instead of NP", nor will I refer to the ACEP policy that makes PAs the preferred "midlevel" provider in the ED.

This hypothetical NP, or any other provider who would send home such a hypothetical patient, needs remediation and closer supervision.
I agree (hypothetically....:)). I was in the room the day Dr Lawrence(then president of ACEP) made her famous statement about PAs being the non-physician provider of choice in EM. As I recall, she got a standing ovation from all the docs and PAs in the room and a few boos from the NPs present at this large national conference.....
 
Last edited by a moderator:
I agree (hypothetically....:)). I was in the room the day Dr Lawrence(then president of ACEP) made her famous statement about PAs being the non-physician provider of choice in EM. As I recall, she got a standing ovation from all the docs and PAs in the room and a few boos from the NPs present at this large national conference.....
Not to start a flame war, but what's their reasoning that PAs are supposedly so much preferable to NPs?
 
Most healthy dudes with hypovolemia from a relatively benign etiology look pretty good. Anyone seen a flu patient this season? Febrile, tachycardic, dry mucous membranes from a few days of n/v/d – and they're fluid responsive and feel a bit better after an antipyretic, an antiemetic, and a couple liters of IVF. AKI? Yeah, duh. It's up to the patient – admit and possible $10k+ inpatient stay for further hydration and work-up or give him a chance to PO rehydrate for free and follow-up with his PCP in 24-48 to see if the Cr is normalizing as expected. I'm not making this guy sign AMA paperwork if he's made a competent, informed decision regarding his own healthcare – considering I probably would have wanted to go home, too!

Everyone posting above putting this guy into the severe sepsis/MICU/CT/AAA/broad-spectrum antibiotics box is wrong. All such suggested pathologies and possibilities are absolutely considerations, but none of them were correct. This hypothetical patient was well, did well. Everyone who suggested otherwise wasted resources and increased the chance of iatrogenic harm. Most patients have self-limited disease and, quite frankly, do fine in spite of their medical care.
 
  • Like
Reactions: 1 user
Not to start a flame war, but what's their reasoning that PAs are supposedly so much preferable to NPs?
I think it's two reasons.

#1: We work for you. While there is a (growing) fringe of PAs who are fighting for autonomous practice (mostly in response to the NPs growing autonomy), most PAs realize we don't have near your education and therefore YOU need to be involved. Meanwhile NPs are equating the DNP with MD/DO, and fighting for autonomous practice everywhere.

#2: The education difference between PA and NP (even the DNP) is immense. We learn much of what you learn in med school, which allows us to think about patients the same way you do. They don't.

Not trying to hijack the thread.....
 
Everyone posting above putting this guy into the severe sepsis/MICU/CT/AAA/broad-spectrum antibiotics box is wrong. All such suggested pathologies and possibilities are absolutely considerations, but none of them were correct. This hypothetical patient was well, did well. Everyone who suggested otherwise wasted resources and increased the chance of iatrogenic harm. Most patients have self-limited disease and, quite frankly, do fine in spite of their medical care.

I completely disagree. Patients with severe sepsis have a mortality rate greater than 20%. You may send patients with severe sepsis home without a diagnosis, but I do not. And had he wanted to leave, I absolutely would have had him sign AMA paperwork. This patient could have been bacteremic or had one of a hundred different life threatening etiologies. Maybe he was developing watershed ischemia from hypotension, and the diarrhea is a symptom rather than the primary etiology? Further, the fact that this turned out to be norovirus and not something requiring broad spectrum antibiotics could not have been known on the first visit, and the fact that he did well was nothing but luck on a mismanaged case. I should go further to state that even from a viral etiology he could have suffered great morbidity, and it is lucky that he did not.

Most healthy dudes with hypovolemia from a relatively benign etiology look pretty good. Anyone seen a flu patient this season? Febrile, tachycardic, dry mucous membranes from a few days of n/v/d – and they're fluid responsive and feel a bit better after an antipyretic, an antiemetic, and a couple liters of IVF.

I also do not think a young, healthy patient with known influenza who comes in with tachycardia and fever is an accurate comparison. (I also do not typically consider patients with isolated nausea, vomiting, and diarrhea to have influenza.) We see that everyday and after their influenza comes back positive, we have an etiology, unlike in this case. We can make a plan based on that known diagnosis. On this visit we do not know what the etiology is. He was sent home with severe sepsis, etiology unknown, inappropriately dispositioned, inappropriately managed, and whoever sent him home is very lucky.
 
Last edited:
This patient had severe sepsis as evidenced by hypotension responsive to fluids, 2+ SIRS criteria, acute kidney injury, and was systemically ill from an infectious ideology.

Personally, I would have begun an antibiotic to cover infectious diarrhea, but that's just my clinical judgment.

Discharging this patient home after IV fluids is an extreme outlier among emergency providers.
 
This patient had severe sepsis as evidenced by hypotension responsive to fluids, 2+ SIRS criteria, acute kidney injury, and was systemically ill from an infectious ideology.

Personally, I would have begun an antibiotic to cover infectious diarrhea, but that's just my clinical judgment.

Discharging this patient home after IV fluids is an extreme outlier among emergency providers.
SIRS based definitions of "sepsis" are worthless. They tell you nothing you didn't know before applying the rule.

By these definitions, a tachypneic, tachycardia and hypothermic trauma, as well as a febrile/tachycardia kid with a cold, and a dying patient with blood cultures + for meningiococcus, all go in the same or similar bucket.


Hypovolemic shock, from dehydration due to a severe viral enteritis alone explains this "hypothetical."

Yet everyone wants to make everyone "septic."

No wonder they can't find benefit from early goal directed therapy. Everyone is "septic" now, as they've let the definition devolve from those sickest from bacterial illness (as defined by + blood cultures) now to anyone who's sick with abnormal vital signs, from anything or things "suspected."

How many diagnoses have been missed or negative antibiotic-associated outcomes caused, because people were thrown too early into the "SIRS/septic" bucket to get EGDT, only to end up having another cause of serious illness?
 
Last edited:
SIRS based definitions of "sepsis" are worthless. They tell you nothing you didn't know before applying the rule.

By these definitions, a tachypneic, tachycardia and hypothermic trauma, as well as a febrile/tachycardia kid with a cold, and a dying patient with blood cultures + for meningiococcus, all go in the same or similar bucket.

Actually the definition of sepsis is not worthless, this is a straightforward sepsis case, not a hypotensive trauma patient or someone in acute pain, and the definition of sepsis and SIRS criteria are designed to prevent people from sending exactly this patient home inappropriately.

Hypovolemic shock, from dehydration due to a severe viral enteritis alone explains this "hypothetical."

Yet everyone wants to make everyone "septic."

That's because this patient is obviously septic. You don't know this is viral at the outset. The appropriate treatment for this patient is exactly EGDT and admission. If you take a group of 100 of these patients exactly like this and send them all home, how many do you think end up having positive blood cultures? How many would die before they came back to the hospital? The idea of chalking this up to viral at the outset is ridiculous, so is sending this patient home.
No wonder they can't find benefit from early goal directed therapy.

What? No benefit from EGDT? EGDT has decreased the mortality rate of sepsis twofold. It is one of the most obviously beneficial concepts in the last 15 years in medicine. You can debate which details in EGDT are most important, i.e. Process trial, but there's no question EGDT is beneficial.
Everyone is "septic" now, as they've let the definition devolve from those sickest from bacterial illness (as defined by + blood cultures) now to anyone who's sick with abnormal vital signs, from anything or things "suspected."

Once again you should not be diagnosing sepsis in hindsight. And if 100% of the patients you treat for sepsis in the ED end up with positive blood cultures, you are not treating sepsis aggressively enough.

How many diagnoses have been missed or negative antibiotic-associated outcomes caused, because people were thrown too early into the "SIRS/septic" bucket to get EGDT, only to end up having another cause of serious illness?

Once again this is the question people were asking 25 years ago when the mortality from sepsis was 40-50%.
 
Actually the definition of sepsis is not worthless, this is a straightforward sepsis case, not a hypotensive trauma patient or someone in acute pain, and the definition of sepsis and SIRS criteria are designed to prevent people from sending exactly this patient home inappropriately.



That's because this patient is obviously septic. You don't know this is viral at the outset. The appropriate treatment for this patient is exactly EGDT and admission. If you take a group of 100 of these patients exactly like this and send them all home, how many do you think end up having positive blood cultures? How many would die before they came back to the hospital? The idea of chalking this up to viral at the outset is ridiculous, so is sending this patient home.


What? No benefit from EGDT? EGDT has decreased the mortality rate of sepsis twofold. It is one of the most obviously beneficial concepts in the last 15 years in medicine. You can debate which details in EGDT are most important, i.e. Process trial, but there's no question EGDT is beneficial.


Once again you should not be diagnosing sepsis in hindsight. And if 100% of the patients you treat for sepsis in the ED end up with positive blood cultures, you are not treating sepsis aggressively enough.



Once again this is the question people were asking 25 years ago when the mortality from sepsis was 40-50%.
It's not real sepsis. It's hypovolemic shock. But by a worthless definition of sepsis, that includes anyone with abnormal vitals signs from any source, yes, you're right, it's sepsis.

Sepsis used to mean + blood cultures and end-stage bacterial infection.

Sepsis now, is everyone with abnormal vital signs by the current day overly-broad and ridiculously non-specific definitions used.

The patient had a virus. Needed only fluids and time and got better without antibiotics. Any definition that calls that sepsis is worthless. Any definition that calls my kids septic every time she gets a virus, with fever and tachycardia, is worthless. This is a flaw in current thinking. It's over treatment and misdiagnosis.
 
  • Like
Reactions: 1 users
Despite your protestations, I stand by my statement all this fear-mongering over sepsis and alternative diagnoses is "wrong". Not wrong in the sense – "you're idiots!" – but wrong in the sense – the ultimate result from the case. All of you are strongly opposed to – the truth. Your pretest probability for horribleness and labeling a person with a physiologic state is disconnected from his actual illness: dehydration secondary to viral enteritis. Are you going to calculate his APACHE II score or trend his SOFA score? For the entire cruise ship?

Medicine isn't supposed to be about CYA and filling the hospital with negative work-ups for "could've beens" – it's about weighing all the factors inherent to a specific case to make an individualized assessment of the likeliest outcome. Was the NP who sent this patient home sophisticated enough to go through that process? Probably not. Could a physician sit down with this guy and offer him a reasonable spectrum of options based on the level of risk the patient is willing to assume? Yeah. This guy doesn't need to be scared into an expensive hospitalization by being forced to sign a form offering basically no additive legal protection. That's not the sort of medicine I'd want practiced on me.
 
  • Like
Reactions: 1 user
Despite your protestations, I stand by my statement all this fear-mongering over sepsis and alternative diagnoses is "wrong". Not wrong in the sense – "you're idiots!" – but wrong in the sense – the ultimate result from the case. All of you are strongly opposed to – the truth. Your pretest probability for horribleness and labeling a person with a physiologic state is disconnected from his actual illness: dehydration secondary to viral enteritis. Are you going to calculate his APACHE II score or trend his SOFA score? For the entire cruise ship?

Medicine isn't supposed to be about CYA and filling the hospital with negative work-ups for "could've beens" – it's about weighing all the factors inherent to a specific case to make an individualized assessment of the likeliest outcome. Was the NP who sent this patient home sophisticated enough to go through that process? Probably not. Could a physician sit down with this guy and offer him a reasonable spectrum of options based on the level of risk the patient is willing to assume? Yeah. This guy doesn't need to be scared into an expensive hospitalization by being forced to sign a form offering basically no additive legal protection. That's not the sort of medicine I'd want practiced on me.
I agree completely that it's not true "sepsis" by any meaningful definition of sepsis, only by worthless SIRS based definitions that gobble up all cause patients with abnormal vitals. The patient needed IVFs, lots of them, and time to absorb it.

People that get better without ever needing an antibiotic were never truly septic, by any meaningful definition.

Only if you drink the Kool aid.
 
Last edited:
This patient had severe sepsis in the same sense that a patient who has chest pain at rest, anterior t wave inversions and a big ol' pulmonary embolus has unstable angina.

When we focus too much on definitions it is at the expense of our understanding.

The degree to which posters on this forum are willing to stridently criticize others is alarming.

That all having been said - if I'd seen this patient on his bounce back visit I would have sent a message to the medical director requesting that his second visit's facility charge be waived. I do this pretty often for bounce backs.
 
  • Like
Reactions: 1 user
The degree to which posters on this forum are willing to stridently criticize others is alarming.
"Pride goeth before the fall"


I agree with this. It's a point I made on the Ebola thread when everyone was ready to burn at the stake, those that missed the sentinel, first-ever-in-the-history-of-all-of-eternity case of something in the USA. It's a serious flaw and ubiquitous part of medical culture, unfortunately, and carries over to our medical-legal system: Excessive hubris.

Everyone is too quick to throw everyone else under the bus to show how smart they supposedly are. It's all fine and good until someone else, including the same names on your own textbooks, throw you under the bus:

http://www.epmonthly.com/features/c...-slippery-slope-for-dubious-expert-testimony/
 
I think it's two reasons.

#1: We work for you. most PAs realize we don't have near your education and therefore YOU need to be involved. Meanwhile NPs are equating the DNP with MD/DO, and fighting for autonomous practice everywhere.

#2: The education difference between PA and NP (even the DNP) is immense. We learn much of what you learn in med school, which allows us to think about patients the same way you do. They don't.
YUP, THIS.
2nd yr of pa school is for all intents and purposes the MS3 year and at many places PA and med students are scheduled interchangeably for that year. PAs get a true clinical year with 2000-3000 hrs of training in multiple specialties after a 1st didactic year which includes most of MS2 and parts of MS1. Many NPs get 500-800 hrs of clinicals, done part time in a single specialty. PAs always work with docs to some extent. even if they work solo there is a doc somewhere in the picture reviewing and commenting on the care to critique mistakes so they are not repeated. Also, ACEP was very involved with setting up many of the 27 EM PA residencies currently in existence and helped to design the CAQ exam for EM PAs so that it would be a significant marker of skill in the specialty. EM PAs sit on many ACEP committees and EM physicians interact regularly with the board of SEMPA (Soc. of EM PAs).
 
YUP, THIS.
2nd yr of pa school is for all intents and purposes the MS3 year and at many places PA and med students are scheduled interchangeably for that year. PAs get a true clinical year with 2000-3000 hrs of training in multiple specialties after a 1st didactic year which includes most of MS2 and parts of MS1. Many NPs get 500-800 hrs of clinicals, done part time in a single specialty. PAs always work with docs to some extent. even if they work solo there is a doc somewhere in the picture reviewing and commenting on the care to critique mistakes so they are not repeated.
I agree with the training differences, in theory, but the differences in competence are irrelevant. The ideal midlevel/physician-extender/PA/NP (or whatever term you want to use) depended on the practice setting. In the CMG or employed ED setting, it is one who,

1-Does not increase your workload, and

2-Is 100% medical-legally independent (so you're 0% legally responsible) always.

Right now, as far as I'm concerned, the EM business model has pitted MDs and PAs against one another in an employed or CMG setting. Reason: working with a PA increases a doc's med-mal exposure, and realistically, any increased profit seen from the PA is likely to be skimmed by the employer and never given to the doc. In this set up, the PA is not the physicians assistant, the PA is the employer's assistant, by allowing them to profit off increased liability for the physician, with increased (or at best unchanged) case load at the same time. I'd much rather have an NP working independently without forcing me to co-sign or be liable for charts. At that point the responsibility of ensuring competence is not with the physician, it is with the employer and overseer of the midlevel, who is not the physician working side by side with them.

In a physician private-practice setting, however, a PA can actually function as a physician's "assistant" whereas he/she is selected, trained, hired/fired and employed by the physician(s) and practice. Any help or "assistance" is of benefit to the doctor, including decreased workload and increased collections.

****That's the whole thing that makes it worth the increased liability.*****

If, if, if.....

It's in a setting where any increased collections are funneled anywhere other than as a defined bonus to the doctor, or without a defined decreased in work load, then it's a net negative for a doctor to have a medical-legally dependent extender, regardless of how effective or competent they are. (In an ED setting, an extender will not ever in reality, decrease physician workload, since there's always an oversupply of patients in the waiting room and the work load is pre-set at a specific patients/provider/per hour; ie, any patient seen by the PA is not one less seen by the doctor, it just frees up the one behind them in line to be seen by the doc instead).

In the CMG or employed ED setting, the best mid-level is not the "best mid-level." It is a medical-legally independent one, regardless of any theoretical differences in training or knowledge base.

In a private practice setting, the best mid-level is precisely, whoever is the best midlevel.

This is something to keep in mind as ED practices shift away from SDGs to a more common CMG or employed model, where mid-level/physician ratios are pushed to increase employer profits, potentially to the detriment of the physician.
 
Last edited:
  • Like
Reactions: 1 users
Top